Thomas W. McElin

The elusive adenomyosis of the uterus--revisited.

Abstract Adenomyosis was found in 61.5 per cent of 200 consecutive uteri removed at Evanston Hospital between July 8, 1969, and April 13, 1970, an incidence much higher than that usually cited. As a symptom, menorrhagia seems to increase in frequency as the degree of uterine involvement by adenomyosis increases. Dysmenorrhea apparently increases in frequency as the depth of penetration and degree of involvement by adenomyosis increases. Adenomyosis subbasalis appears to be an important symptom-producing entity. A summation particularly designed to assist in the diagnosis of adenomyosis is presented.

Premenstrual tension: Symptoms and weight changes related to potassium therapy

Abstract With the use of patients with and without evidence of premenstrual tension, a study was done in which comparison of weight changes and symptoms were evaluated during control menstrual cycles, menstrual cycles when a placebo (glucose) was taken, and menstrual cycles when a diuretic (potassium chloride) was taken. It was found that the clinician can make a verifiable diagnosis of premenstrual tension. While the symptoms of this entity could not be correlated with premenstrual weight gain, they could be with lability of weight during the 5 days preceding menses. In fact, in all of the cycles (control, placebo, and diuretic-treated), there was found to be a highly significant gain in weight in the 5 days premenses. The use of oral potassium chloride supplements in gelatine capsules had no effect on symptoms reported by patients with premenstrual tension.

Puerperal hematomas: Report of 73 cases and review of the literature☆

Abstract We have reviewed the literature of the last decade relating to puerperal hematomas. We have attempted to compile a total listing of possible causative factors, a total listing of the symptoms which have been reported, and a complete tabulation of the various therapeutic suggestions that have been offered so that these data might be easily available in one communication. We have studied our own experience and find it in general accord with that of the literature. There was no maternal mortality in our series. One-third of the patients were morbid. Over one-half of the patients were primigravidas. Prolonged labor did not seem to be an etiological factor. We found no prolongation of the second stage of labor in this study. Nonetheless, it seems eminently logical that such prolongation might well increase the incidence of puerperal blood tumors. The type of anesthesia appeared to be of no significance. It is undoubtedly true that saddle block anesthesia may prevent the early complaint of inordinate pain. Obviously, more vigilant postpartum supervision is necessary for these patients. The incidence of forceps delivery (73 per cent) in this series is much higher than in all but one of the previously reported studies. Hamilton noted an overall operative incidence of 42 per cent in all the cases in the literature. Our high incidence of forceps delivery as well as our high incidence of occurrence suggests to us that trauma may be an important etiological factor. We are compelled, for example, to disagree with the terminology employed by McNally and Ehrlich 10 in their recent publication and with one of their conclusions. They report 52 instances of puerperal hematomas with an incidence of 80 per cent operative delivery (low forceps). This is the only series that has come to our attention with a higher operative incidence than our own. They contend that, with the exception of one breech delivery and 3 patients delivered by the Scanzoni maneuver, “all patients can be considered to have delivered normally” and that trauma is not, therefore, a significant etiological factor. These patients may have delivered in the usual fashion, i.e., saddle block anesthesia with low forceps delivery, but not in the normal fashion and such statistics (80 per cent operative delivery) most certainly do not exclude trauma as a causative item. In terms of therapy, it may be unequivocally stated that active management is surely indicated for the expanding varieties. Not to be obscured by the plea for conservative obstetrics (nontraumatic delivery, meticulous episiotomy closure, and precise hemostasis) and the plea for active therapy , when indicated, is the important suggestion that the obstetrical diagnostican must be alert to the very possibility that this complication may occur Delay in diagnosis means needless destruction of tissue . Early recognition is crucial.

Late postoperative vaginal vault disruption: Report of a case

Abstract A case is presented of vaginal vault rupture and evisceration occurring with minimal trauma 3½ months after abdominal hysterectomy for preinvasive cervical carcinoma. Minimal posthysterectomy febrile morbidity was present, and vaginal vault granulation tissue requiring cautery may have indicated less than optimal vault healing. However, both of these features are relatively common-place. This late complication of hysterectomy is very rare, more so after the abdominal than the vaginal operation.

Use of buccal Pitocin for the elective induction of labor

Abstract Using buccal Pitocin during a 4 year period 911 elective inductions of labor were performed. From among 8,109 deliveries the total induction frequency was 30 per cent, of which 80 per cent were with buccal Pitocin. The success rate of the 911 inductions was 96.9 per cent. The average Apgar rating was 8.6. There were no instances of fetal death. Morbidity for mother and baby are compared. The results for this population of patients and physicians in this hospital are considered most favorable.

Pessary complications in the management of uterine prolapse

Abstract Two cases illustrating pessary complications in the management of uterine prolapse have been presented. The second case was particularly unusual and nearly catastrophic. The current literature has been specifically reviewed for the purpose of listing pessary mishaps. No other instance of intravaginal strangulation of a prolapsed uterus through a pessary was found. A listing of the factors necessary for the rational and safe employment of the pessary in the management of uterine prolapse has been presented.

THE EFFECT OF FETAL MONITORING ON THE INCIDENCE OF CESAREAN SECTION

To determine whether routine fetal monitoring inevitably increases the cesarean section rate, we studied the pertinent literature and analyzed the cesarean sections performed at Evanston Hospital during the last 8 years. Many authors have found a slight to moderate increase in cesarean section rates, whereas others have found no change or a decrease. At Evanston Hospital, the primary cesarean section rate has increased from 2.6% in 1968-1969 to 6.9% in 1974-1975. Only 19.2% of this increase is due to increased fetal distress; the magnitude of the increase is due to changes in other factors, notably, breech deliveries (29.5% of the increase) and “dystocia” (60.2% of the increase). The incidence of cesarean section is controlled by several complex variables, only one of which is fetal monitoring. To describe the fetal monitors as the cause of the increased cesarean section rate is to ignore these other equally profound changes in obstetric technic and philosophy.

Muscular hyperplasia ("cirrhosis") of the lung complicated by pregnancy

Abstract A case of muscular hyperplasia (“cirrhosis”) of the lung is presented. This may be the first report of this disease in a pregnant patient. Because of symptomatic and functional deterioration, the pregnancy was interrupted and sterilization performed. While the histologic pattern was typical of this condition, the physiologic changes were mixed, with both obstructive and restrictive ventilatory abnormalities. The patient died of pulmonary failure 6 years after lung biopsy (with the clinical diagnosis of a chronic lung disorder) and 9 years after the onset of pulmonary symptoms.

The microbiological environment of a rooming-in maternity☆☆☆

Abstract A review of the literature and an analysis of the changing conditions which have identified coagulase-positive hemolytic Staphylococcus aureus as the primary endemic and epidemic menace in hospital environments has been presented. A detailed description has been provided of the six different physical environments in which newborn infants reside in the patient-care areas of the newly constructed (1959) Rooming-In Maternity of the Evanston Hospital. A comprehensive, 2 year analysis of the microbiological environments of these six infant care areas and of the related nurseries is detailed in which a total of 2,222 bacteriological samples, both human and environmental, were processed.